Oocyte cryopreservation

ICSI sperm injection into oocyte

Human oocyte cryopreservation (egg freezing) is a process in which a woman’s eggs (oocytes) are extracted, frozen and stored. Later, when she is ready to become pregnant, the eggs can be thawed, fertilized, and transferred to the uterus as embryos.

Indications

Oocyte cryopreservation is aimed at three particular groups of women: those diagnosed with cancer who have not yet begun chemotherapy or radiotherapy; those undergoing treatment with assisted reproductive technologies who do not consider embryo freezing an option; and those who would like to preserve their future ability to have children, either because they do not yet have a partner, or for other personal or medical reasons.

Over 50,000 reproductive-age women are diagnosed with cancer each year in the United States.[1] Chemotherapy and radiotherapy are toxic for oocytes, leaving few, if any, viable eggs. Egg freezing offers women with cancer the chance to preserve their eggs so that they can have children in the future.

Oocyte cryopreservation is an option for individuals undergoing IVF who object, either for religious or ethical reasons, to the practice of freezing embryos. Having the option to fertilize only as many eggs as will be utilized in the IVF process, and then freeze any remaining unfertilized eggs can be a solution. In this way, there are no excess embryos created, and there need be no disposition of unused frozen embryos, a practice which can create complex choices for certain individuals.

There is a thriving industry marketing freezing eggs at an early age, and it may ensure a chance for a future pregnancy.

Additionally, women with a family history of early menopause have an interest in fertility preservation. With egg freezing, they will have a frozen store of eggs, in the likelihood that their eggs are depleted at an early age.

Method

The egg retrieval process for oocyte cryopreservation is the same as that for in vitro fertilization. This includes one to several weeks of hormone injections that stimulate ovaries to ripen multiple eggs. When the eggs are mature, final maturation induction is performed, preferably by using a GnRH agonist rather than human chorionic gonadotrophin (hCG), since it decreases the risk of ovarian hyperstimulation syndrome with no evidence of a difference in live birth rate (in contrast to fresh cycles where usage of GnRH agonist has a lower live birth rate). [2] The eggs are subsequently removed from the body by transvaginal oocyte retrieval. The procedure is usually conducted under sedation. The eggs are immediately frozen.

The egg is the largest cell in the human body and contains a high amount of water. When the egg is frozen, the ice crystals that form can destroy the integrity of the cell. To prevent this, the egg must be dehydrated prior to freezing. This is done using cryoprotectants which replace most of the water within the cell and inhibit the formation of ice crystals.

Eggs (oocytes) are frozen using either a controlled-rate, slow-cooling method or a newer flash-freezing process known as vitrification. Vitrification is much faster but requires higher concentrations of cryoprotectants to be added. The result of vitrification is a solid glass-like cell, free of ice crystals. Indeed, freezing is a phase transition. Vitrification, as opposed to freezing, is a physical transition. Realizing this fundamental difference, vitrification concept has been developed and successfully applied in IVF treatment with the first life birth following vitrification of oocytes achieved in 1999.[3] Vitrification eliminates ice formation inside and outside of oocytes on cooling, during cryostorage and on warming. Vitrification is associated with higher survival rates and better development compared to slow-cooling when applied to oocytes in metaphase II (MII).[4] Vitrification has also become the method of choice for pronuclear oocytes, although prospective randomized controlled trials are still lacking.[4]

During the freezing process, the zona pellucida, or shell of the egg can be modified preventing fertilization. Thus, currently, when eggs are thawed, a special fertilization procedure is performed by an embryologist whereby sperm is injected directly into the egg with a needle rather than allowing sperm to penetrate naturally by placing it around the egg in a dish. This injection technique is called ICSI (Intracytoplasmic Sperm Injection) and is also used in IVF.

Success rates

The percentage of transferred cycles is lower in frozen cycles compared with fresh cycles (approx. 30% and 50%).[5] Such outcomes are considered comparable.

In a 2013 meta-analysis of more than 2,200 cycles using frozen eggs, scientists found the probability of having a live birth after three cycles was 31.5 percent for women who froze their eggs at age 25, 25.9 percent at age 30, 19.3 percent at age 35, and 14.8 percent at age 40.[6]

Two recent studies showed that the rate of birth defects and chromosomal defects when using cryopreserved oocytes is consistent with that of natural conception.[7][8]

Recent modifications in protocol regarding cryoprotectant composition, temperature and storage methods have had a large impact on the technology, and while it is still considered an experimental procedure, it is quickly becoming an option for women. Slow freezing traditionally has been the most commonly used method to cryopreserve oocytes, and is the method that has resulted in the most babies born from frozen oocytes worldwide. Ultra-rapid freezing or vitrification represents a potential alternative freezing method.

In the fall of 2009, The American Society for Reproductive Medicine (ASRM) issued an opinion on oocyte cryopreservation concluding that the science holds “great promise for applications in oocyte donation and fertility preservation” because recent laboratory modifications have resulted in improved oocyte survival, fertilization, and pregnancy rates from frozen-thawed oocytes in IVF.[9] The ASRM noted that from the limited research performed to date, there does not appear to be an increase in chromosomal abnormalities, birth defects, or developmental deficits in the children born from cryopreserved oocytes. The ASRM recommended that, pending further research, oocyte cryopreservation should be introduced into clinical practice on an investigational basis and under the guidance of an Institutional Review Board (IRB). As with any new technology, safety and efficacy must be evaluated and demonstrated through continued research.

In October 2012, the ASRM lifted the experimental label from the technology for women with a medical need, citing success rates in live births, among other findings. However, they also warned against using it only to delay child-bearing.

In 2014, a Cochrane systematic review about this topic was published. It compared vitrification (the newest technology) versus slow freezing (the oldest one). Key results of that review showed that the clinical pregnancy rate was almost 4 times higher in the oocyte vitrification group than in the slow freezing group, with moderate quality of evidence.[10]

Cost

The cost of the egg freezing procedure (without embryo transfer) in U.S.U.K and other European countries varies in between $5,000 and $12,000. This does not include the fertility medications which can cost between $4,000 and $5,000. Egg storage can vary from $100 to more than $1,000.

In other countries popular for medical tourism or regional tourism ( within the country) , costs may vary. Egg Freezing Costs Worldwide

As an example, in India, which is an upcoming medical tourism country for Infertility & IVF Treatment, egg freezing is catching up, but, there is only one site that publicly has provided costing and it ranges from approximately 700$ (Rs 49,100 INR) for egg freezing including Vitrification cost but excluding fertility medications , as well as approximately 1420$ ( Rs 99,100/- INR) for egg freezing with fertility medications. The website claims to have included fertility medications in the cost of Egg Freezing cycle. Cost of Storage is sited as 180$ per year. Egg Freezing Costs in Indian Oocyte Bank

In other countries ,well established in medical tourism and IVF , Czech Republic, Ukraine , Cyprus etc, are also offering Egg Freezing at competitive prices It is sited as a lower cost alternative to typical US options for egg freezing. Spain and the Czech Republic are popular destinations for this treatment.

The cost for egg freezing abroad may start as low as $2500 per cycle (including medications), but you also need to factor in travel costs for 7 – 10 days in Europe for the stimulation and egg collection per cycle. Frozen oocyte storage costs tend to be slightly less expensive as well, with typical costs as low as $200–300 per year. Cost of Egg Freezing at popular Medical Tourism Centres

History

Cryopreservation itself has always played a central role in assisted reproductive technology. With the first cryopreservation of sperm in 1953 and of embryos thirty years later, these techniques have become routine. Dr Christopher Chen of Singapore reported the world’s first pregnancy in 1986 using previously frozen oocytes.[11] This report stood alone for several years followed by studies reporting success rates using frozen eggs to be much lower than those of traditional in vitro fertilization (IVF) techniques using fresh oocytes. Providing the lead to a new direction in cryobiology, Dr. Lilia Kuleshova was the first scientist to achieve vitrification of human oocytes that resulted in a live birth in 1999.[3] Then recently, two articles published in the journal, Fertility and Sterility, reported pregnancy rates using frozen oocytes that were comparable to those of cryopreserved embryos and even fresh embryos.[12][13] These newer reports affirm that oocyte cryopreservation technology is advancing.

Almost 42,000 'slow frozen' (as opposed to 'vitrified') human embryo transfers were performed during 2001 in Europe (Andersen et al. 2005). In addition, it is estimated that between 300,000 and 500,000 successful human births have resulted worldwide from the transfer of previously ‘slow frozen’ embryos performed from the mid-1970s to 2006.

Social egg freezing

Social egg freezing is a term used to describe the use of egg-freezing as an attempt to delay child-bearing in a non-medical context. There has been a proliferation in the marketing of this kind of egg freezing since October 2012 when the ASRM lifted the experimental label from the technology, despite their explicit warning against these uses given the risks assumed by the woman and the child.

There was another spike in interest in 2014 when it was revealed[14] that Facebook and Apple were adding egg freezing as a benefit for their female employees. This announcement was controversial, with some women finding it useful or empowering, and others finding it alienating or misguided.

A string of “egg freezing parties” by third-party companies have also helped popularize the concept among young women.[15]

Risks

The risks involved with egg freezing for the women undergoing the procedure are the same as the risks from egg extraction for the purposes of IVF. These include: bleeding from the oocyte recovery procedure, reaction to the hormones used to induce hyperovulation (producing more than one egg), including ovarian hyperstimulation syndrome (OHSS) and, rarely, liver failure. The long-term effects of egg extraction on women’s bodies have not been well studied.

There may also be some risks to any resulting child. These will include any of the risks associated with IVF,[16] as well as potential unknown risks caused by long-term freezing, which are currently unknown. Expanded use of Intracytoplasmic sperm injection (ICSI) to inject a single sperm into a thawed egg could additionally be a cause for concern as this method has been associated with a higher rate of birth defects.

See also

References

  1. ↑ American Cancer Society (2001) Cancer facts and figures 2001. Atlanta: American Cancer Society. Retrieved on April 24, 2007.
  2. ↑ Youssef, Mohamed AFM; Van der Veen, Fulco; Al-Inany, Hesham G; Mochtar, Monique H; Griesinger, Georg; Nagi Mohesen, Mohamed; Aboulfoutouh, Ismail; van Wely, Madelon; Youssef, Mohamed AFM (2014). "Cochrane Database of Systematic Reviews". doi:10.1002/14651858.CD008046.pub4. |chapter= ignored (help)
  3. 1 2 Kuleshova, Lilia; Gianoroli, Luca; Magli, Cristina; Ferraretti, Anna; Trounson, Alan (1999). "Birth following vitrification of small number of human oocytes". Human Reproduction. 14 (12): 3077–3079. doi:10.1093/humrep/14.12.3077.
  4. 1 2 Edgar, D. H.; Gook, D. A. (2012). "A critical appraisal of cryopreservation (slow cooling versus vitrification) of human oocytes and embryos". Human Reproduction Update. 18 (5): 536. doi:10.1093/humupd/dms016.
  5. ↑ Magli MC, Lappi M, Ferraretti AP, Capoti A, Ruberti A, Gianaroli L (March 2009). "Impact of oocyte cryopreservation on embryo development". Fertil. Steril. 93 (2): 510–516. doi:10.1016/j.fertnstert.2009.01.148. PMID 19342025.
  6. ↑ http://www.asrm.org/uploadedFiles/ASRM_Content/News_and_Publications/News_and_Research/Press_Releases/2013-05/Live%20birth%20probability%20with%20egg%20freezing.pdf
  7. ↑ Noyes N, Porcu E, Borini A. (2009) With more than 900 babies born, live birth outcomes following oocyte cryopreservation do not appear different from those occurring after conventional IVF. Reprod Biomed Online 18:769-776.
  8. ↑ CNN April 16, 2007 . Retrieved on April 24, 2007
  9. ↑ ASRM Practice Committee. (2009) ASRM Practice Committee response to Rybak and Lieman: elective self-donation of oocytes. Fertil Steril 92:1513-514.
  10. ↑ Glujovsky D, Riestra B, Sueldo C, Fiszbajn G, Repping S, Nodar F, Papier S, Ciapponi A. Vitrification versus slow freezing for women undergoing oocyte cryopreservation. Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD010047. DOI: 10.1002/14651858.CD010047.pub2.
  11. ↑ Chen C. (1986) "Pregnancy after human oocyte cryopreservation". Lancet 1 (8486): 884-886. Retrieved on April 24, 2007
  12. ↑ Jain, J.; et al. (2005). "Oocyte cryopreservation". Fertility and Sterility. 86 (4). pp. 1037–1046.
  13. ↑ Grifo, J.; Noyes, N. (2010). "Delivery rate using cyropreserved oocytes is comparable to conventional in vitro fertilization using fresh oocytes: potential fertility preservation for female cancer patients". Fertility and Sterility. 93 (2): 391–396. doi:10.1016/j.fertnstert.2009.02.067. PMID 19439285.
  14. ↑ http://www.npr.org/sections/alltechconsidered/2014/10/17/356765423/silicon-valley-companies-add-new-benefit-for-women-egg-freezing
  15. ↑ http://www.slate.com/articles/health_and_science/medical_examiner/2014/09/egg_freezing_marketing_campaigns_lie_about_success_rates_of_this_fertility.html
  16. ↑ http://healthland.time.com/2012/10/22/ivf-linked-to-more-birth-defects/
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